From the Guidelines
Management of patients with low endothelial cell count and corneal thinning requires a stepwise approach focusing on preservation of remaining endothelial function and corneal integrity. Initial management should include preservative-free lubricating eye drops 4-6 times daily (such as Systane Ultra or Refresh Optive) to maintain ocular surface health, along with hypertonic saline drops (5% sodium chloride) for corneal edema if present, as suggested by the most recent guidelines 1. Patients should avoid eye rubbing and trauma, and use protective eyewear during activities with risk of eye injury. Bandage contact lenses may be considered for persistent epithelial defects, while topical anti-inflammatory medications like loteprednol 0.5% should be used cautiously and only for short periods due to risk of delayed healing and infection. For progressive cases, surgical interventions including Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) or Descemet's Membrane Endothelial Keratoplasty (DMEK) may be necessary to replace damaged endothelial cells, as recommended by recent studies 1. These recommendations aim to preserve corneal function by protecting remaining endothelial cells, which are critical for maintaining corneal deturgescence through their pump function, and by supporting the compromised corneal structure that results from thinning. Some key considerations in the management of these patients include:
- The use of preservative-free artificial tears to facilitate sufficient movement of the lens when a bandage contact lens is used 1
- The potential benefits and risks of topical corticosteroids in reducing intraocular and corneal inflammation, while monitoring for steroid-related complications 1
- The importance of regular follow-up to reassess the lens, look for evidence of a change in the patient’s ocular status, and re-emphasize the need for vigilance on the part of the patient 1
- The role of surgical interventions, including DSAEK and DMEK, in replacing damaged endothelial cells and preserving corneal function 1.
From the Research
Management Recommendations
- Patients with low endothelial cell count and corneal thinning require careful management to prevent further damage and promote corneal health 2, 3.
- Corneal cross-linking (CXL) can be a treatment option for patients with progressive keratoconus or other corneal thinning conditions, but it may cause transient corneal thinning and endothelial cell loss 4.
- Cataract surgery can be performed in eyes with low endothelial cell density, but it is essential to monitor endothelial cell count and central corneal thickness preoperatively and postoperatively 5, 6.
- The use of topical medical therapy, laser procedures, and glaucoma surgeries should be carefully considered in patients with low endothelial cell density, as they can have adverse effects on the corneal endothelium 3.
Factors Affecting Prognosis
- A shorter axial length (<23.0 mm) and diabetes mellitus are risk factors for greater endothelial cell loss and bullous keratopathy in patients with low endothelial cell density undergoing cataract surgery 6.
- Posterior capsule rupture during cataract surgery is also a risk factor for bullous keratopathy in patients with low endothelial cell density 6.
- Fuchs dystrophy, laser iridotomy, keratoplasty, traumatic injury, trabeculectomy, and corneal endotheliitis are preoperative diagnoses or factors that can contribute to endothelial cell loss 6.
Monitoring and Follow-up
- Regular monitoring of endothelial cell count and central corneal thickness is crucial in patients with low endothelial cell density and corneal thinning 2, 5.
- Specular microscopy can be used to monitor endothelial cell health and function 2.
- Patients with low endothelial cell density and corneal thinning should be followed up regularly to assess the progression of their condition and adjust their management plan as needed 3, 6.